Healthcare Provider Details

I. General information

NPI: 1407817752
Provider Name (Legal Business Name): MARK F. COOK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 HIGHLAND BLVD
JOHNSON CREEK WI
53038-9504
US

IV. Provider business mailing address

412 HIGHLAND BLVD
JOHNSON CREEK WI
53038-9504
US

V. Phone/Fax

Practice location:
  • Phone: 920-390-9038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2358-035
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2358-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: